Initial experience with combined heart-liver transplantation in the Netherlands: Exploring the boundaries of isolated and combined transplantation.

Heart transplantation is considered as the ultimate treatment for patients with advanced heart failure (HF). Chronic HF is associated with hepatic congestion and reduced cardiac output, which can lead to progressive liver disease. This issue is particularly relevant in patients with congenital heart disease, especially those with a single functional ventricle managed through Fontan-type surgery. The presence of advanced liver disease may contraindicate isolated heart transplantation and thus require consideration of combined heart-liver transplantation (CHLT). However, consensus criteria for CHLT have not yet been established. To illustrate the clinical and scientific discussions on this topic, we present the clinical course of two patients with a Fontan circulation who were evaluated for CHLT and discuss decision-making factors based on a review of current literature. We conclude that establishing a CHLT program represents a promising therapeutic pathway for patients in the Netherlands with advanced HF and concomitant liver disease. Both isolated heart transplantation and CHLT are viable treatment approaches for carefully selected patients with HF and liver disease. However, early identification of potential candidates and timely referral for a comprehensive evaluation are essential for the effective management of this high-risk patient group.